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Bağlı İ, Öcal E, Bala M, Tahaoğlu Z, Bakır MS, Halisçelik MA, Bademkıran C, Gül E. Uterine isthmic tourniquet left in situ as a new approach for placenta previa-accreta surgery: a comparative study. J Perinat Med 2024; 0:jpm-2024-0243. [PMID: 39097938 DOI: 10.1515/jpm-2024-0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/27/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. METHODS In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. RESULTS This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69 ± 1.37 vs. 8.15 ± 1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). CONCLUSIONS The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.
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Affiliation(s)
- İhsan Bağlı
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yaşargil Egitim Araştırma Hastanesi Ek Bina, Urfa Yolu, Bağlar, 21090, Diyarbakır, Türkiye
| | - Ece Öcal
- Private Clinic of Perinatology, Diyarbakır, Türkiye
| | - Mesut Bala
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Türkiye
| | - Zelal Tahaoğlu
- Department of Obstetrics and Radiology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Türkiye
| | - Mehmet Sait Bakır
- Department of Gynecologic Onkology, Mersin City Hospital, Mersin, Türkiye
| | - Mesut Ali Halisçelik
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Türkiye
| | - Cihan Bademkıran
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Türkiye
| | - Erdoğan Gül
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Türkiye
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Pichatechaiyoot A, Suphasynth Y, Sae-Sue T, Atjimakul T, Rattanaburi A, Nanthamongkolkul K, Jiamset I. Comparative study of the prevalence of organ injury in placenta accreta spectrum disorder between posterior colpotomy and conventional peripartum hysterectomies at a single referral center in southern Thailand. Int J Gynaecol Obstet 2024. [PMID: 38961834 DOI: 10.1002/ijgo.15768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/28/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To compare the prevalence of adjacent organ injury in placenta accreta spectrum disorder (PAS) between the posterior colpotomy approach and conventional peripartum hysterectomy. METHODS This retrospective study analyzed the data of pregnant women diagnosed with PAS who underwent peripartum hysterectomy at Songklanagarind Hospital between January 2006 and December 2021. The patients were divided into two groups: posterior colpotomy and conventional approaches. The characteristics and surgical and obstetric outcomes were compared. Univariate and multivariate logistic regression was used to identify factors and risk of organ injury. RESULTS Among 174 patients, 64 underwent conventional peripartum hysterectomy, and 110 underwent the posterior colpotomy approach. The overall incidence of adjacent organ injury was 17.82%. Organ injury prevalence was lower in the posterior colpotomy group (10%) than in the conventional group (31.25%), with no difference in operative time. Multivariate analysis showed that posterior colpotomy reduced adjacent organ injury (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.06-0.54, P = 0.002). Placenta percreta was associated with increased injury risk (OR 6.83, 95% CI 2.53-18.44, P < 0.002). Subgroup analysis showed that the posterior approach reduced bladder injury in placenta increta (OR 0.14, 95% CI 0.04-0.57, P = 0.003) and percreta (OR 0.19, 95% CI 0.05-0.77, P = 0.017). CONCLUSION Compared with conventional peripartum hysterectomy, the posterior colpotomy approach in patients with PAS reduced the risk of adjacent organ injury, particularly for placenta increta and percreta. This technique should be considered in PAS cases, but further investigations with a prospective study design are needed.
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Affiliation(s)
- Aroontorn Pichatechaiyoot
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Yuthasak Suphasynth
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thitaporn Sae-Sue
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thiti Atjimakul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Athithan Rattanaburi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Kulisara Nanthamongkolkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Ingporn Jiamset
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Pineles BL, Coselli J, Ghorayeb T, Fishel Bartal M, Zvavanjanja RC, Blackwell SC, Papanna R, Sibai BM. Leaving the Placenta In Situ in Placenta Accreta Spectrum Disorders: A Single-Center Case Series. Am J Perinatol 2024; 41:e420-e429. [PMID: 35752168 DOI: 10.1055/a-1885-1942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The most common treatment for placenta accreta spectrum (PAS) disorders is planned primary cesarean hysterectomy. However, other management strategies may improve outcomes and/or allow fertility preservation. The objective of this study was to describe the course and outcomes of patients with PAS managed by leaving the placenta in situ. STUDY DESIGN This is a series of 11 patients with PAS managed by leaving the placenta in situ at a single academic center in the United States from 2015 to 2022. The approach described involves delivery of the fetus via cesarean, no attempt at placental removal, closure of the hysterotomy, prophylactic intravenous antibiotics for up to 1 week, and close outpatient follow-up until the uterus is empty. RESULTS The uterus was successfully preserved in six (55%), minimally invasive hysterectomy was performed in four (36%), and abdominal hysterectomy was performed in 1 (9%). During cesarean delivery, the median estimated blood loss was 650mL (range: 200-1,000mL). The majority of patients had no vaginal discharge for several weeks after delivery, followed by brown or bloody discharge, and intermittent mild-to-moderate cramping. The median time to resolution of PAS was 18 weeks in patients with successful uterine preservation (range: 5-25 weeks). Indications for hysterectomy included hemorrhage (n=1), coagulopathy (n=1), endomyometritis (n=2), and pain (n=1), and these occurred at a median of 5 weeks postpartum (range: 1-25 weeks). Four patients had subsequent pregnancies of whom three were live births at or near term and one was a spontaneous abortion at 19 weeks. CONCLUSION Leaving the placenta in situ may be an appropriate management strategy for some carefully selected and counseled patients with PAS. KEY POINTS · Overall, 55% had uterine preservation (6/11).. · Minimally invasive approach in 80% of hysterectomies (4/5).. · Of patients, 67% with uterine preservation had subsequent pregnancies (4/6)..
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Affiliation(s)
- Beth L Pineles
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Jennie Coselli
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Tala Ghorayeb
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Michal Fishel Bartal
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Rodrick C Zvavanjanja
- Department of Diagnostic and Interventional Radiology, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Texas
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Nguyen PN, Vuong ADB, Pham XTT. Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation. BMC Pregnancy Childbirth 2024; 24:228. [PMID: 38566074 PMCID: PMC10986094 DOI: 10.1186/s12884-024-06349-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes. METHODS This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes. RESULTS Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001. CONCLUSIONS Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.
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Affiliation(s)
- Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
| | - Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Xuan Trang Thi Pham
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
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Lauroy A, Buffeteau A, Vidal F, Parant O, Guerby P. [French survey on the management strategy for placenta accreta spectrum]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00092-8. [PMID: 38556130 DOI: 10.1016/j.gofs.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Placenta accreta belongs to placenta accreta spectrum and is defined by an adhesion or even invasion of the placental villi in the myometrium. The main risk factor is a history of cesarean section. Its incidence is increasing following an increase in the cesarean section rate in recent years and the cause of severe maternal morbidity (hemorrhage, transfusions, hysterectomy). Treatment can be radical by cesarean section-hysterectomy or conservative with an attempt at uterine preservation. American, English, Canadian and international recommendations have been established but there are no French recommendations to date. The objective of this study was to investigate management strategy for placenta accreta in type III maternity hospitals in France. MATERIALS AND METHODS An anonymous questionnaire was sent by email to the obstetrics referents of the university hospital centers in France with type III maternity. RESULTS Forty-eight centers were approached, with a participation rate of 77%. CONCLUSION The management of placenta accreta spectrum in France is relatively heterogeneous on several points such as multidisciplinary management, evaluation by placental MRI, preoperative urological evaluation, treatment adopted as first-line, cesarean section-hysterectomy or conservative treatment, therapeutic strategy according to the placental invasion. However, the literature is currently poor, which may explain divergent treatment.
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Affiliation(s)
- Aurianne Lauroy
- Service de gynécologie-obstétrique Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande Bretagne TSA 70034, 31059 Toulouse, France.
| | - Aurélie Buffeteau
- Service de gynécologie-obstétrique Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande Bretagne TSA 70034, 31059 Toulouse, France
| | - Fabien Vidal
- Service de chirurgie gynécologique clinique de La Croix du Sud, 31130 Quint-Fonsegrives, France
| | - Olivier Parant
- Université des Antilles Hyacinthe-Bastaraud, Pointe à Pitre, 97110 Guadeloupe, France
| | - Paul Guerby
- Service de gynécologie-obstétrique Paule-de-Viguier, CHU de Toulouse, 330, avenue de Grande Bretagne TSA 70034, 31059 Toulouse, France; Infinity CNRS Inserm U1291, université Paule-Sabatier Toulouse III, Toulouse, France
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Zheng C, Zhong J, Wang Y, Cao K, Zhang C, Yue P, Xu X, Yang Y, Liu Q, Zou Y, Huang B. Deep Learning Radiomic Analysis of MRI Combined with Clinical Characteristics Diagnoses Placenta Accreta Spectrum and its Subtypes. J Magn Reson Imaging 2024. [PMID: 38390981 DOI: 10.1002/jmri.29317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Different placenta accreta spectrum (PAS) subtypes pose varying surgical risks to the parturient. Machine learning model has the potential to diagnose PAS disorder. PURPOSE To develop a cascaded deep semantic-radiomic-clinical (DRC) model for diagnosing PAS and its subtypes based on T2-weighted MRI. STUDY TYPE Retrospective. POPULATION 361 pregnant women (mean age: 33.10 ± 4.37 years), suspected of PAS, divided into segment training cohort (N = 40), internal training cohort (N = 139), internal testing cohort (N = 60), and external testing cohort (N = 122). FIELD STRENGTH/SEQUENCE Coronal T2-weighted sequence at 1.5 T and 3.0 T. ASSESSMENT Clinical characteristics such as history of uterine surgery and the presence of placenta previa, complete placenta previa and dangerous placenta previa were extracted from clinical records. The DRC model (incorporating radiomics, deep semantic features, and clinical characteristics), a cumulative radiological score method performed by radiologists, and other models (including a radiomics and clinical, the clinical, radiomics and deep learning models) were developed for PAS disorder diagnosing (existence of PAS and its subtypes). STATISTICAL TESTS AUC, ACC, Student's t-test, the Mann-Whitney U test, chi-squared test, dice coefficient, intraclass correlation coefficients, least absolute shrinkage and selection operator regression, receiver operating characteristic curve, calibration curve with the Hosmer-Lemeshow test, decision curve analysis, DeLong test, and McNemar test. P < 0.05 indicated a significant difference. RESULTS In PAS diagnosis, the DRC-1 outperformed than other models (AUC = 0.850 and 0.841 in internal and external testing cohorts, respectively). In PAS subtype classification (abnormal adherent placenta and abnormal invasive placenta), DRC-2 model performed similarly with radiologists (P = 0.773 and 0.579 in the internal testing cohort and P = 0.429 and 0.874 in the external testing cohort, respectively). DATA CONCLUSION The DRC model offers efficiency and high diagnostic sensitivity in diagnosis, aiding in surgical planning. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Changye Zheng
- Department of Radiology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Jian Zhong
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
- Guangdong Key Laboratory of Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
| | - Ya Wang
- Dongguan Maternal and Child Health Care Hospital, Dongguan, China
| | - Kangyang Cao
- Faculty of Applied Sciences, Macao Polytechnic University, Macao, China
| | - Chang Zhang
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
- Guangdong Key Laboratory of Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
| | - Peiyan Yue
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
- Guangdong Key Laboratory of Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
| | - Xiaoyang Xu
- Department of Radiology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Yang Yang
- Department of Radiology, Suining Central Hospital, Suining, China
| | - Qinghua Liu
- Dongguan Maternal and Child Health Care Hospital, Dongguan, China
| | - Yujian Zou
- Department of Radiology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Bingsheng Huang
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
- Guangdong Key Laboratory of Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, China
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Peng L, Yang Z, Liu J, Liu Y, Huang J, Chen J, Su Y, Zhang X, Song T. Prenatal Diagnosis of Placenta Accreta Spectrum Disorders: Deep Learning Radiomics of Pelvic MRI. J Magn Reson Imaging 2024; 59:496-509. [PMID: 37222638 DOI: 10.1002/jmri.28787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Diagnostic performance of placenta accreta spectrum (PAS) by prenatal MRI is unsatisfactory. Deep learning radiomics (DLR) has the potential to quantify the MRI features of PAS. PURPOSE To explore whether DLR from MRI can be used to identify pregnancies with PAS. STUDY TYPE Retrospective. POPULATION 324 pregnant women (mean age, 33.3 years) suspected PAS (170 training and 72 validation from institution 1, 82 external validation from institution 2) with clinicopathologically proved PAS (206 PAS, 118 non-PAS). FIELD STRENGTH/SEQUENCE 3-T, turbo spin-echo T2-weighted images. ASSESSMENT The DLR features were extracted using the MedicalNet. An MRI-based DLR model incorporating DLR signature, clinical model (different clinical characteristics between PAS and non-PAS groups), and MRI morphologic model (radiologists' binary assessment for the PAS diagnosis) was developed. These models were constructed in the training dataset and then validated in the validation datasets. STATISTICAL TESTS The Student t-test or Mann-Whitney U, χ2 or Fisher exact test, Kappa, dice similarity coefficient, intraclass correlation coefficients, least absolute shrinkage and selection operator logistic regression, multivariate logistic regression, receiver operating characteristic (ROC) curve, DeLong test, net reclassification improvement (NRI) and integrated discrimination improvement (IDI), calibration curve with Hosmer-Lemeshow test, decision curve analysis (DCA). P < 0.05 indicated a significant difference. RESULTS The MRI-based DLR model had a higher area under the curve than the clinical model in three datasets (0.880 vs. 0.741, 0.861 vs. 0.772, 0.852 vs. 0.675, respectively) or MRI morphologic model in training and independent validation datasets (0.880 vs. 0.760, 0.861, vs. 0.781, respectively). The NRI and IDI were 0.123 and 0.104, respectively. The Hosmer-Lemeshow test had nonsignificant statistics (P = 0.296 to 0.590). The DCA offered a net benefit at any threshold probability. DATA CONCLUSION An MRI-based DLR model may show better performance in diagnosing PAS than a clinical or MRI morphologic model. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Lulu Peng
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jue Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Yi Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Jianwei Huang
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Junwei Chen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Yun Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Xiang Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Ting Song
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
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Feng X, Mao X, Zhao J. Clinical Characteristics, Prenatal Diagnosis and Outcomes of Placenta Accreta Spectrum in Different Placental Locations: A Retrospective Cohort Study. Int J Womens Health 2024; 16:155-162. [PMID: 38292300 PMCID: PMC10826409 DOI: 10.2147/ijwh.s439654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Abstract
Objective To explore the prenatal diagnosis, clinical characteristics, and perinatal outcomes of placenta accreta spectrum in different placental locations. Methods This was a retrospective cohort study. Pregnant women who delivered at two tertiary referral hospitals from January 2013 to December 2022 and were ultimately pathologically diagnosed with placenta accreta spectrum were included. They were divided into three groups based on different placental locations (anterior, posterior, and lateral wall/fundus). The differences in prenatal diagnosis, clinical characteristics, and perinatal outcomes among the three groups were compared. Results There were 115,470 deliveries in a ten-year period at the two hospitals, and 118 case patients were confirmed to have a pathologically diagnosed placenta accreta spectrum. The posterior placenta group had a lower rate of placenta previa (76.9% vs 94.9% vs 100%, p<0.05) and a higher gestational age at delivery (36.4±2.45 vs 34.91±1.76 vs 34.31±3.41, p<0.05) compared to the other two groups. The anterior placenta group had a significantly higher rate of invasive (increta/percreta) form placenta accreta spectrum (81.4% vs 36.5% vs 28.6%, p<0.05) and planned cesarean section (96.6% vs 80.8% vs 71.4%, p<0.05) compared to the other two groups. In terms of prenatal diagnosis, the anterior placenta group had a significantly higher rate of placenta accreta spectrum prenatal suspicion rate compared to the other two groups (86.4% vs 36.5% vs 57.1%, p<0.05). The posterior placenta group had a lower rate of preoperative abdominal aortic balloon placement compared to the other two groups (5.8% vs 28.8% vs 28.6%, p<0.05). There were no statistically significant differences among the three groups in primary perinatal outcomes, though the anterior placenta group had a longer postoperative hospital stay. Conclusion The prenatal diagnosis rate and proportion of invasive form of placenta accreta spectrum occurring in non-anterior placenta are relatively lower than anterior placenta. There were no significant differences in major perinatal outcomes among the three groups.
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Affiliation(s)
- Xiaoling Feng
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, People’s Republic of China
| | - Xun Mao
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, People’s Republic of China
| | - Jianlin Zhao
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, People’s Republic of China
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Zhao J, Li Q, Liao E, Shi H, Luo X, Zhang L, Qi H, Zhang H, Li J. Incidence, risk factors and maternal outcomes of unsuspected placenta accreta spectrum disorders: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:76. [PMID: 38262978 PMCID: PMC10804779 DOI: 10.1186/s12884-024-06254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/03/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND To identify incidence and underlying risk factors for unsuspected placenta accreta spectrum (PAS) and compare the maternal outcomes between suspected and unsuspected cases in three large academic referral centers. METHODS A retrospective cohort study was conducted in three university-based tertiary referral centers from Jan 1st, 2013, to Dec 31st, 2022. All cases of PAS confirmed by pathology were included in the study. Unsuspected PAS cases were diagnosed at the time of delivery, while suspected cases served as the control group. Potential risk factors were compared between the two groups. Multivariable regression model was also performed to identify risk factors. Maternal outcomes were also evaluated. RESULTS A total of 339 pathology-confirmed PAS cases were included in the study out of 415,470 deliveries, of which 35.4% (n = 120) were unsuspected cases. Unsuspected PAS cases were 7.9 times more likely to have a history of intrauterine adhesions (adjusted odds ratio [aOR] 7.93; 95% confidence interval [CI] 2.35-26.81), 7.0 times more likely to have a history of clinically confirmed PAS (aOR, 6.99; 95% CI 2.85-17.18), 6.3 times more likely to have a posterior placenta (aOR, 6.30; 95% CI 3.48-11.40), and 3.4 times more likely to have a history of placenta previa (aOR, 3.41; 95% CI 1.18-9.82). On the other hand, cases with gravidity > 3, placenta previa, and/or a history of previous cesarean delivery were more likely to be diagnosed antenatally (aOR 0.40, 0.19, 0.36; 95% CI 0.22-0.74, 0.09-0.40, 0.19-0.70). Although the suspected PAS group had a higher proportion of invasive cases and abdominal and pelvic organ injuries (74.4% vs. 25.8%, p < 0.001; 6.8% vs. 1.7%, p = 0.037), the maternal outcomes were more favorable in the sPAS group, with a lower median volume of 24-hour blood loss and blood product transfusion (estimated blood loss in 24 h, 1000 [800-2000] vs. 2000 [1400-2400], p < 0.001; RBC unit transfusion, 0 [0-800] vs. 800 [600-1000], p < 0.001; fresh-frozen plasma transfusion, 0 [0-450] vs. 600 [400-800], p < 0.001). CONCLUSIONS Our findings indicate that 35% of patients with PAS were unsuspected prior to delivery. Factors associated with PAS being unsuspected prior to delivery include a history of intrauterine adhesions, a history of clinically confirmed PAS, a posterior placenta, and a history of placenta previa. Additionally, gravidity > 3, a history of previous cesarean delivery, and placenta previa increase the likelihood of antenatal diagnosis.
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Affiliation(s)
- Jianlin Zhao
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Qin Li
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
| | - E Liao
- Department of Obstetrics and Gynecology, Maternal and Child Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, Hubei Province, China
| | - Haijun Shi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Xin Luo
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Lan Zhang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Hongbo Qi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
| | - Hua Zhang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China.
| | - Junnan Li
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China.
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Salmanian B, Shamshirsaz AA, Fox KA, Asl NM, Erfani H, Detlefs SE, Coburn M, Espinoza J, Nassr A, Belfort MA, Clark SL, Shamshirsaz AA. Clinical Outcomes of a False-Positive Antenatal Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2024; 41:187-192. [PMID: 34666389 DOI: 10.1055/a-1673-5103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. STUDY DESIGN This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. RESULTS A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. CONCLUSION Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. KEY POINTS · Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes.. · Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected.. · Patients with suspected placenta accreta rarely undergo unindicated hysterectomy..
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Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | | | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med 2023; 36:2183764. [PMID: 36966802 DOI: 10.1080/14767058.2023.2183764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE To demonstrate the surgical and morbidity differences between upper and lower parametrial placenta invasion (PPI). MATERIALS AND METHODS Forty patients with placenta accreta spectrum (PAS) into the parametrium underwent surgery between 2015 and 2020. Based on the peritoneal reflection, the study compared two types of parametrial placental invasion (PPI), upper or lower. Surgical approach to PAS follows a conservative-resective method. Before delivery, surgical staging by pelvic fascia dissection established a final diagnosis of placental invasion. In upper PPI cases, the team attempted to repair the uterus after resecting all invaded tissues or performing a hysterectomy. In cases of lower PPI, experts performed a hysterectomy in all cases. The team only used proximal vascular (aortic occlusion) control in cases of lower PPI. Surgical dissection for lower PPI started finding the ureter in the pararectal space, ligating all the tissues (placenta and newly formed vessels) to create a tunnel to release the ureter from the placenta and placenta suppletory vessels. Overall, at least three pieces of the invaded area were sent for histological analysis. RESULTS Forty patients with PPI were included, 13 in the upper parametrium and 27 in the lower parametrium. MRI indicated PPI in 33/40 patients; in three, the diagnosis was presumed by ultrasound or medical background. The intrasurgical staging categorizes 13 cases of PPI performed and finds diagnosis in seven undetected cases. The expertise team completed a total hysterectomy in 2/13 upper PPI cases and all lower PPI cases (27/27). Hysterectomies in the upper PPI group were performed by extensive damage of the lateral uterine wall or with a tube compromise. Ureteral injury ensued in six cases, corresponding to cases without catheterization or incomplete ureteral identification. All aortic vascular proximal control (aortic balloon, internal aortic compression, or aortic loop) was efficient for controlling bleeding; in contrast, ligature of the internal iliac artery resulted in a useless procedure, resulting in uncontrollable bleeding and maternal death (2/27). All patients had antecedents of placental removal, abortion, curettage after a cesarean section, or repeated D&C. CONCLUSIONS Lower PAS parametrial involvement is uncommon but associated with elevated maternal morbidity. Upper and lower PPI has different surgical risks and technical approaches; consequently, an accurate diagnosis is needed. The clinical background of manual placental removal, abortion, and curettage after a cesarean or repeated D&C could be ideally studied to diagnose a possible PPI. For patients with high-risk antecedents or unsure ultrasound, a T2 weight MRI is always recommended. Performing comprehensive surgical staging in PAS allows the efficient diagnosis of PPI before using some procedures.
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12
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Li R, Tang X, Qiu X, Wang W, Wang Q. Associations of characteristics of previous induced abortion with different grades of current placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2023; 36:2253349. [PMID: 37648652 DOI: 10.1080/14767058.2023.2253349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/19/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE Induced abortion could increase the risk of placenta accreta spectrum (PAS) in the next pregnancy. We aimed to explore the associations between characteristics of previous induced abortion and grades of current PAS. METHODS A retrospective case-control study was performed in eligible pregnant women with PAS between January 2014 and June 2022. Data collected included demographics, obstetric characteristics, and information on previous induced abortion. RESULTS The study included 211 pregnant women, with 51 and 160 in the invasive (placenta increta or percreta) and adherence (placenta creta) PAS groups, respectively. The risk of invasive PAS was 14.3-fold higher in patients with abnormal vaginal bleeding after abortion (odds ratio = 14.3, 95% confidence interval 5.6-36.4, p < .01) than those without abnormal vaginal bleeding and approximately 5.8-fold higher in patients with the last induced abortion ≥5 years ago than those within 5 years (odds ratio = 5.8, 95% confidence interval 2.2-15.2, p < .01). The risk of invasive PAS was 13.4-fold higher in patients with placenta attached to uterine cornu than patients with the placenta attached to uterine wall (odds ratio = 17.5, 95% confidence interval 5.5-55.5, p < .01). The number of previous induced abortions, hospital grades, and gestational age at abortion were not different between two groups. CONCLUSION In pregnant women with a history of induced abortion, abnormal vaginal bleeding after induced abortion and prolonged duration after the last induced abortion increased the risk for invasive PAS in the current pregnancy. The number of previous induced abortions and gestational age at abortion had no relation to the grades of PAS.
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Affiliation(s)
- Rui Li
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaoqin Tang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xia Qiu
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wan Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Qi Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Teixeira B, Pinto PV, Realista R, Silva M, Costa A, Machado AP, Moucho M. Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e747-e753. [PMID: 38141594 DOI: 10.1055/s-0043-1772482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVE To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). METHODS Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. RESULTS During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. CONCLUSION After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.
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Affiliation(s)
- Beatriz Teixeira
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rodrigo Realista
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuela Silva
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Antónia Costa
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ana Paula Machado
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina Moucho
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
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Overton E, Wen T, Friedman AM, Azad H, Nhan-Chang CL, Booker WA, Khoury-Collado F, Mourad M. Outcomes associated with peripartum hysterectomy in the setting of placenta accreta spectrum disorder. Am J Obstet Gynecol MFM 2023; 5:101174. [PMID: 37802412 DOI: 10.1016/j.ajogmf.2023.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Although peripartum hysterectomy for placenta accreta spectrum disorder is known to be associated with complications at the time of delivery, there are limited data on postpartum outcomes and readmission risk in this population. OBJECTIVE This study aimed to analyze risks for adverse outcomes and postpartum readmissions in the setting of peripartum hysterectomy for placenta accreta spectrum disorder by severity of placenta accreta spectrum disorder subcategory. STUDY DESIGN Using the 2016-2020 Nationwide Readmissions Database, this retrospective cohort study identified peripartum hysterectomies with a diagnosis of placenta accreta spectrum disorder. The primary exposure was placenta accreta spectrum disorder, subcategorized as placenta accreta vs increta/percreta. The primary outcome was readmission rate and delivery complications. Complications evaluated included the following: (1) nontransfusion severe maternal morbidity (ntSMM), (2) venous thromboembolism, (3) reoperation, (4) intraoperative complications, (5) hemorrhage, (6) sepsis, and (7) surgical site complications. We additionally evaluated delivery hospitalization and readmission mean length of stay, and hospital costs. Unadjusted and adjusted logistic regression models were fit for outcomes adjusting for clinical, demographic, and hospital factors. The association measures were expressed as unadjusted and adjusted odds ratios with 95% confidence intervals. RESULTS Between 2016 and 2020, 7864 hysterectomies during a delivery hospitalization with a diagnosis of placenta accreta spectrum disorder were identified (66.5% with placenta accreta and 33.5% with placenta increta/percreta diagnoses). The overall 60-day all-cause readmission rate was 7.3%. Most readmissions (57.2%) occurred within 10 days of hospital discharge. Compared with peripartum hysterectomy with a diagnosis of placenta accreta, hysterectomies with placenta increta/percreta diagnoses carried significantly increased risk of 60-day readmission (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.71), inpatient mortality (odds ratio, 13.23; 95% confidence interval, 3.35-52.30), nontransfusion severe maternal morbidity (adjusted odds ratio, 1.43; 95% confidence interval, 1.20-1.71), intraoperative complications (adjusted odds ratio, 2.31; 95% confidence interval, 1.93-2.77), and surgical site complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.23-1.95). The median length of stay during delivery hospitalization was longer for placenta increta/percreta (5.8 days; 95% confidence interval, 5.4-6.1) than for placenta accreta (4.2 days; 95% confidence interval, 4.1-4.3; P<.05). In addition, delivery hospitalization costs were higher in cases of placenta increta/percreta (median, $30,686; 95% confidence interval, $28,922-$32,449) than placenta accreta (median, $21,321; 95% confidence interval, $20,480-$22,163). CONCLUSION Complication and readmission risks after peripartum hysterectomy with placenta accreta spectrum disorder are high. Compared with patients with placenta accreta, patients with placenta increta/percreta had increased risk for delivery and postoperative complications and postpartum readmission, and increased costs and length of stay.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad).
| | - Timothy Wen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA (Dr Wen)
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Fady Khoury-Collado
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101197. [PMID: 37865220 DOI: 10.1016/j.ajogmf.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med 2023; 36:2183741. [PMID: 37193605 DOI: 10.1080/14767058.2023.2183741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/20/2022] [Accepted: 02/18/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Describe the clinical-surgical results of patients with PAS in the low-posterior cervical-trigonal space associated with fibrosis (PAS type 4) compared with PAS types in other locations (Types 1, upper bladder, 2 in upper parametrium) and in particular with PAS type 3, corresponding to dissectible cervical-trigonal invasion. The clinical-surgical results of using a standard hysterectomy were analyzed with a modified subtotal hysterectomy (MSTH) in patients with PAS type 4. MATERIAL AND METHODS A descriptive, retrospective, multicenter study included 337 patients of PAS; thirty-two corresponding to PAS type 4, from three PAS reference hospitals, CEMIC, Buenos Aires, Argentina, Fundación Valle de Lili, Cali, Colombia, and Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2015 and December 2020. PAS was diagnosed by abdominal and transvaginal ultrasound and topographically characterized by ultrafast T2 weighted MRI. In persistent macroscopic hematuria after MSTH, the surgeon performs an intentional cystotomy and uses a square compression suture to achieve the hemostasis inside the bladder wall.According to a PAS topographical classification, the patients with low-vesical cervical involvement compared with PAS located in relation with the upper blader (type1), upper parametrium (type 2 upper), and also with PAS situated in the lower vesical-trigon space (type 3). PAS 3 and 4 are located in identical area, but in type 3, group A, the vesicouterine space was dissectible, and in type 4, group B, significant fibrosis made surgical dissection extremely challenging. Furthermore, group B was divided into patients treated with total hysterectomy (HT) and those treated with a modified subtotal hysterectomy (MSTH). The surgical requirements to perform an MSHT included the availability of proximal vascular control at the aortic level (internal manual aortic compression, aortic endovascular balloon, aortic loop, or aortic cross-clamping). Then surgeon performed an upper segmental hysterotomy, avoiding the abnormal placenta invasion area; after that, the fetus was delivered, and the umbilical cord was ligated.After uterine exteriorization, the surgeon applies a continuous circular suture with number 2 polyglactin 910, taking some portions of the myometrium -to avoid unintentional slipping- around the lower uterine segment and a 3-4 cm proximal to the abnormal adhesion of the placenta. After tightening hard the circular suture, the uterine segment was circumferentially cut, three centimeters proximal to the circular hemostatic sutures. Next, the surgery follows the upper steps of conventional hysterectomy without changes. Additionally, the histological presence of fibrosis was examined in all samples. RESULTS Modified subtotal hysterectomy in patients with PAS type 4 (cervical-trigonal fibrosis) resulted in a significant clínico-surgical improvement over total hysterectomy. The median operative time and intraoperative bleeding were 140 min (IQR 90--240) and 1895 mL (IQR 1300-2500) in patients undergoing modified subtotal hysterectomy, and 260 min (IQR 210-287) and 2900 mL (IQR 2150-5500) in patients treated with total hysterectomy, respectively. The complication rate was 20% for MSHT and 82.3% for patients with a total hysterectomy. CONCLUSIONS PAS in the cervical trigonal area associated with fibrosis implies a greater risk of complications due to uncontrollable bleeding and organ damage. MSTH is associated with lower morbidity and difficulties in PAS type 4. Prenatal or intrasurgical diagnosis is essential to plan surgical alternatives to improve the results.
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Affiliation(s)
| | | | - Rozi Aditya Aryananda
- Universitas Airlangga, Surabaya, Indonesia
- Placenta Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia
- Dr. Soetomo Academic General Hospital, City of Buenos Aires, Argentina
| | | | - Clara Ivette Campos
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
| | - Grace Ariani
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
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17
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Lucidi A, Jauniaux E, Hussein AM, Coutinho CM, Tinari S, Khalil A, Shamshirsaz A, Palacios-Jaraquemada JM, D'Antonio F. Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:633-643. [PMID: 37401769 DOI: 10.1002/uog.26299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/16/2023] [Accepted: 04/21/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). METHODS MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data. RESULTS There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis. CONCLUSIONS Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Lucidi
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - E Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - A M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - C M Coutinho
- Department of Gynecology and Obstetrics, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paolo, Brazil
| | - S Tinari
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| | - A Shamshirsaz
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - J M Palacios-Jaraquemada
- CEMIC University Hospital and School of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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18
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Berman ZT, Boone CE, Melber DJ, Ballas J, Parikh R, Ramos G, Kelly T, McHale M, Picel AC, Roberts AC. Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum. J Vasc Interv Radiol 2023; 34:1915-1921. [PMID: 37527770 DOI: 10.1016/j.jvir.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/16/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS). MATERIALS AND METHODS An institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded. RESULTS A total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475-1,000 mL) compared to 2,000 mL (IQR, 1,500-2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3-9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed. CONCLUSIONS Prophylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.
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Affiliation(s)
- Zachary T Berman
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California.
| | - Christine E Boone
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Dora J Melber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Rupal Parikh
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Gladys Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Thomas Kelly
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Michael McHale
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Andrew C Picel
- Department of Radiology, Division of Interventional Radiology, Stanford University, Stanford, California
| | - Anne C Roberts
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
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Matsuo K, Sangara RN, Matsuzaki S, Ouzounian JG, Hanks SE, Matsushima K, Amaya R, Roman LD, Wright JD. Placenta previa percreta with surrounding organ involvement: a proposal for management. Int J Gynecol Cancer 2023; 33:1633-1644. [PMID: 37524496 DOI: 10.1136/ijgc-2023-004615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Sue E Hanks
- Department of Radiology, University of Southern California, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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20
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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101027. [PMID: 37211089 DOI: 10.1016/j.ajogmf.2023.101027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa. DATA SOURCES A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022. STUDY ELIGIBILITY CRITERIA The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa. METHODS Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa. CONCLUSION The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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21
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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22
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Khoury-Collado F, Newton JM, Brook OR, Carusi DA, Shrivastava VK, Crosland BA, Fox KA, Khandelwal M, Karam AK, Bennett KA, Sandlin AT, Shainker SA, Einerson BD, Belfort MA. Surgical Techniques for the Management of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:970-979. [PMID: 37336214 DOI: 10.1055/s-0043-1761636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..
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Affiliation(s)
- Fady Khoury-Collado
- Division of Gynecologic Oncology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vineet K Shrivastava
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital, University of California Irvine, Irvine, California
| | - Brian A Crosland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Karin A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Amer K Karam
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam T Sandlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Scott A Shainker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Michael A Belfort
- Departments of Obstetrics and Gynecology, Surgery, Anesthesiology and Neurosurgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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23
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Abstract
Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.
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Affiliation(s)
- Mahmoud Abdelwahab
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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24
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Liu H, Zhang B, Wang W, Li H, Huang X, Wang J, Han J, Zhu H. Effect of placenta location detected by ultrasound on the severity of placenta accreta spectrum in patients with placenta previa and placenta accreta spectrum. BMC Pregnancy Childbirth 2023; 23:406. [PMID: 37264325 DOI: 10.1186/s12884-023-05736-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/25/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND To evaluate the effect of placental location on the severity of placenta accreta spectrum (PAS). METHODS We analyzed 390 patients with placenta previa combined with placenta accreta spectrum who underwent cesarean section between January 1, 2014 and December 30, 2020 in the electronic case database of the Second Hospital of Hebei Medical University. According to the position of the placenta, 390 placentas were divided into the posterior group (n = 89), the anterior group (n = 60) and the non-central group (n = 241). RESULTS The history of cesarean delivery rates in the anterior group (91.67%) and the non-central group (85.71%) were statistically different from the posterior group (63.74%)(P < 0.001). Univariate logistic regression results showed that employment, urban living, gestational age, complete placenta previa, fetal presentation shoulder, gravidity, cesarean section and vaginal delivery were all predictors for the severity of placenta accreta (P < 0.05). The anterior group (P = 0.001, OR = 4.13, 95%CI: 1.84-9.24) and the non-central group (P = 0.001, OR = 2.90, 95%CI: 1.55-5.45) had a higher incidence of invasive accreta placentation than the posterior group, and were independent risk factors for invasive accreta placentation. CONCLUSION Compared with posterior placenta, anterior and non-central placenta are independent risk factors for invasive PAS in patients with placenta previa, during which we should be more cautious in treatment.
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Affiliation(s)
- Hong Liu
- Department of Physical Examination Center, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Baolian Zhang
- Department of Physical Examination Center, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Wenli Wang
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Haiyan Li
- Department of Ultrasound in Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xianghua Huang
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
| | - Jia Wang
- Department of Quality Control, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jing Han
- Department of Physical Examination Center, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - He Zhu
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Giuseppe C, Salvatore P, Federica C, Francesco L, Francesco D, Alessandro L, Gloria C. Urinary tract injuries during surgery for placenta accreta spectrum disorders. Eur J Obstet Gynecol Reprod Biol 2023; 287:93-96. [PMID: 37300983 DOI: 10.1016/j.ejogrb.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The main purpose of this study was to report the incidence of lower urinary tract injuries (UTI) during cesarean section (CS) hysterectomy in cases of Placenta Accreta Spectrum (PAS) disorders. Study design Retrospective analysis including all women with a prenatal diagnosis of PAS between January 2010 and December 2020. A dedicated multidisciplinary team was involved to define a tailored management for each patient. All relevant demographic parameters, risk factors, degree of placental adhesion, type of surgery, complications and operative outcomes were reported. RESULTS One hundred and fifty-six singleton gestations with a prenatal diagnosis PAS were included in the analysis. 32.7% of cases were classified as PAS 1 (grade 1-3a FIGO classification), 20.5% as PAS 2 (grade 3b FIGO classification) and 46.8% as PAS 3 (grade 3c FIGO classification). A CS hysterectomy was performed in all cases. Surgical complication occurred in seventeen cases (0% in PAS 1, 12.5% in PAS 2 cases and in 17.8% in PAS 3). The incidence of UTI in our series was 7.6% in all women with PAS, including 8 cases of bladder and 12 of ureteral lesion, and 13.7 % in those with PAS 3 only. CONCLUSION Despite advances in prenatal diagnosis and management, surgical complications, mainly those involving the urinary system, still occur in a significant proportion of women undergoing surgery for PAS. The findings from this study highlight the need for a multidisciplinary management of women with PAS in centers with high expertise in prenatal diagnosis and surgical management of these conditions.
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Affiliation(s)
- Calì Giuseppe
- Fondazione per gli Studi sulla Riproduzione Umana, Clinica Candela, Palermo, Italy
| | - Polito Salvatore
- Gynecology and Obstetrics, "Villa Sofia Cervello" Hospital, University of Palermo, Palermo, Italy
| | - Calò Federica
- Gynecology and Obstetrics, Policlinico "P. Giaccone", University of Palermo, Palermo, Italy
| | - Labate Francesco
- Gynecology and Obstetrics, "Villa Sofia Cervello" Hospital, University of Palermo, Palermo, Italy
| | | | - Lucidi Alessandro
- Department of Obstetrics and Gynecology, University of Chieti, Italy.
| | - Calagna Gloria
- Gynecology and Obstetrics, "Villa Sofia Cervello" Hospital, University of Palermo, Palermo, Italy
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Li H, Lu T, Li M, Wang Y, Zhang F, Yuan Y, Zhu M, Zhao X. Differentiation of placenta percreta through MRI features and diffusion-weighted magnetic resonance imaging. Insights Imaging 2023; 14:93. [PMID: 37222836 DOI: 10.1186/s13244-023-01448-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/09/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES To identify whether parameters measured from diffusion kurtosis and intravoxel incoherent motion help diagnose placenta percreta. METHODS We retrospectively enrolled 75 patients with PAS disorders including 13 patients with placenta percreta and 40 patients without PAS disorders. Each patients underwent diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI). The apparent diffusion coefficient (ADC), perfusion fraction (f), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), mean diffusion kurtosis (MK) and mean diffusion coefficient (MD) were measured by the volumetric analysis and compared. MRI features were also analyzed and compared. The receiver operating characteristic (ROC) curve and logistic regression analysis were used to evaluate the diagnostic efficiency of different diffusion parameters and MRI features for distinguishing placental percreta. RESULTS D* was an independent risk factor from DWI for predicting placenta percreta with sensitivity of 73% and specificity of 76%. Focal exophytic mass remained as independent risk factor from MRI features for predicting placenta percreta with sensitivity of 72.7% and specificity of 88.1%. When the two risk factors were combined together, the AUC was the highest, 0.880 (95% CI 0.8-0.96). CONCLUSION D* and focal exophytic mass were associated with placenta percreta. A combination of the 2 risk factors can be used to predict placenta percreta. CRITICAL RELEVANCE STATEMENT A combination of D* and focal exophytic mass can be used to differentiate placenta percreta.
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Affiliation(s)
- Hang Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Tao Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China.
| | - Mou Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Feng Zhang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Yi Yuan
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Meilin Zhu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Xinyi Zhao
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
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Einerson BD. Conservative management for placenta accreta spectrum: questions and barriers remain but are surmountable. Am J Obstet Gynecol MFM 2023; 5:100859. [PMID: 36717353 PMCID: PMC10324967 DOI: 10.1016/j.ajogmf.2023.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/27/2022] [Accepted: 12/31/2022] [Indexed: 01/30/2023]
Affiliation(s)
- Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT.
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Einerson BD, Kennedy A, Silver RM, Branch DW, Comstock J, Woodward PJ. Ultrasonography of the Explanted Uterus in Placenta Accreta Spectrum: Correlation With Intraoperative Findings and Gross Pathology. Obstet Gynecol 2023; 141:544-554. [PMID: 36735356 PMCID: PMC9974826 DOI: 10.1097/aog.0000000000005075] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/10/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To better understand placenta accreta spectrum (PAS) by correlating postoperative ultrasonographic findings of the explanted uteroplacental interface with intraoperative findings and gross pathology. METHODS We enrolled consecutive pregnant patients aged 18 years and older with a prior cesarean delivery and antenatal diagnosis of lower uterine segment PAS who planned to undergo hysterectomy into this prospective, descriptive study. All underwent cesarean hysterectomy with standardized intraoperative photography. Ultrasonography of explanted postsurgical uteruses was performed by expert radiologists to obtain standard detailed images of the myometrial-placental interface and other areas of interest. Sagittal views of the gross pathologic specimen were photographed. We correlated the intraoperative, ultrasonographic, and gross pathologic findings as a study team and report four consistent patterns that emerged from this systematic evaluation. RESULTS Thirty-four consecutive eligible patients were enrolled. The following consistent observations emerged: 1) The uteroplacental interface in the explanted specimen was smooth and distinct. At the point of maximal placental protrusion, the myometrium was imperceptible, but the placenta was confined by a smooth thin echogenic line of uterine serosa (the scar shell) unless surgically disrupted. 2) Every specimen of PAS grade 2-3 showed placenta bulging through the lower uterine segment in the region of prior hysterotomy. 3) Placentas extended to, but not through, the uterovesical interface or scar shell. Dense adhesive disease was found between the placenta and bladder. There were no cases of true bladder invasion. 4) Placental extension beyond the serosa (invasion) has a distinct appearance on postoperative ultrasonography with irregular frond-like protrusion of placental tissue. This appearance was always the result of surgical manipulation and was not present before delivery of the neonate. CONCLUSION These findings suggest that PAS severity is likely mediated by progressive scar dehiscence and uterine remodeling, not placental invasion. This challenges the existence of in situ invasive percreta as it is currently described.
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Affiliation(s)
- Brett D. Einerson
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - Anne Kennedy
- University of Utah Health, Department of Radiology and Imaging Sciences
| | - Robert M. Silver
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - D. Ware Branch
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - Jessica Comstock
- Primary Children’s Hospital
- University of Utah Health, Department of Pathology
| | - Paula J. Woodward
- University of Utah Health, Department of Radiology and Imaging Sciences
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Köhler Silva C, Almeida Ghezzi CL, Vettori DV, Rostirolla GF, Vettorazzi J. Performance of magnetic resonance imaging to predict maternal outcomes in patients at high risk for placenta accreta spectrum disorder. Br J Radiol 2023; 96:20220822. [PMID: 36802974 PMCID: PMC10078882 DOI: 10.1259/bjr.20220822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE The purpose of this study is to evaluate the diagnostic performance of MRI parameters to predict adverse maternal peripartum outcomes in pregnant females at high-risk for placenta accreta spectrum (PAS) disorder. METHODS AND MATERIALS This retrospective study evaluated 60 pregnant females who underwent MRI for placental assessment. MRI studies were reviewed by a radiologist blinded to all clinical data. MRI parameters were compared with five maternal outcomes: severe bleeding, cesarean hysterectomy, prolonged operation time, need for blood transfusion, and need for intensive care unit (ICU) admission. The MRI findings were associated with pathologic and/or intraoperative findings for PAS. RESULTS The study identified 46 cases of PAS disorder and 16 cases of placenta percreta. The agreement between the radiologist impression of PAS disorder and the intraoperative/histological findings was substantial (0.67, p < 0.001), and almost perfect for the presence of placenta percreta (0.87, p < 0.001). The presence of a placental bulge was highly associated with placenta percreta, with sensitivity of 87.5% and specificity of 90.9%. The MRI signs that associated with more maternal outcomes were myometrial thinning, with significant odds ratio for severe blood loss (20.2), hysterectomy (4.0), need for blood transfusion (4.8) and prolonged surgery time (4.9), and uterine bulging, with significant odds ratio for severe blood loss (11.9), hysterectomy (34.0), ICU admission (5.0), and need for blood transfusion (4.8). CONCLUSION MRI signs significantly correlated with invasive placenta and were independently associated with adverse maternal outcomes. The presence of a placental bulge was highly accurate in predicting placenta percreta. ADVANCES IN KNOWLEDGE First study to evaluate the strength of the association between individual MRI signs and five adverse maternal outcomes. Conclusions support published MRI signs associated with placental invasion, especially regarding the value placental bulging in predicting placenta percreta.
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Affiliation(s)
- Cristiano Köhler Silva
- Department of Radiology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | | | | | - Gabriela Françoes Rostirolla
- Postgraduate Program in Health Sciences: Gynecology and Obstetrics at Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Ultrasonographic Prediction of Placental Invasion in Placenta Previa by Placenta Accreta Index. J Clin Med 2023; 12:jcm12031090. [PMID: 36769741 PMCID: PMC9918036 DOI: 10.3390/jcm12031090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023] Open
Abstract
This study aimed to investigate the diagnostic accuracy of the placenta accreta index (PAI) for predicting placenta accreta spectrum (PAS) in women with placenta previa. We analyzed 33 pregnancies with placenta previa at Keio University Hospital. The PAI was assessed in the early third trimester, and PAS was diagnosed histologically or clinically defined as retained placenta after manual removal attempts. The PAI and incidence of PAS were analyzed. Ten women (30%) were diagnosed with PAS and had higher volumes of perioperative bleeding (p = 0.016), higher rate of requiring uterine artery embolization (p = 0.005), and peripartum hysterectomy (p = 0.0002) than women without PAS. A PAI > 2 was the most useful cut-off point for predicting PAS and was more sensitive than prediction values using traditional evaluation (history of cesarean section and placental location). Post-hoc analysis revealed a higher rate of previous history of cesarean delivery (30% vs. 4.4%, p = 0.038), severe placental lacunae (≥grade2) (70% vs. 8.7%, p = 0.0003), thin myometrial thickness (90% vs. 22%, p = 0.0003), anterior placenta (100% vs. 30%, p = 0.0002), and presence of bridging vessels (30% vs. 0%, p = 0.0059) in PAS women. PAI could help predict the outcomes of women with placenta previa with and without a history of cesarean delivery to reduce PAS-induced perinatal complications.
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Chen Y, Peng P, Li C, Teng L, Liu X, Liu J, Cao D, Zhu L, Lang J. Abdominal pregnancy: a case report and review of 17 cases. Arch Gynecol Obstet 2023; 307:263-274. [PMID: 35474494 PMCID: PMC9837172 DOI: 10.1007/s00404-022-06570-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the clinical characteristics of abdominal pregnancy, and to explore the diagnosis and prognosis of different treatment methods. METHODS The cases of patients with abdominal pregnancy admitted to Peking Union Medical College Hospital between January 1, 1989 and January 1, 2021, were analyzed retrospectively. RESULTS The median age of 17 patients was 34 years (22-42 years); the median gestational duration was 57 days (from 41 days to 32 weeks). Among all 17 patients, 15 (88.24%) presented with abdominal pain. The implantation sites of the gestational sac included the bladder peritoneal reflection, anterior wall of the rectum, omentum, serous membrane of the uterus, and inside or on the surface of uterosacral ligament. In all, only 29.41% cases (5/17) were diagnosed before surgery. All 17 patients were treated via surgery. Further, 58.82% (10/17) patients recovered without complications, 29.41% (5/17) developed fever, 5.88% (1/17) underwent reoperation because of intra-abdominal bleeding, and 5.88% (1/17) developed double lower limb venous thrombosis. All 17 patients survived. CONCLUSION The preoperative diagnosis rate of abdominal pregnancy is low. Planting sites in the pelvic peritoneum and pelvic organs are more common than the others. Laparoscopic surgery in the first trimester of pregnancy can achieve better therapeutic effects. However, the blood supply of the placenta should be fully evaluated before surgery. When it is expected that attempts to remove the placenta will cause fatal bleeding, the placenta can be left in place, but long-term close follow-up should be paid attention to.
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Affiliation(s)
- Yu Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Ping Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Chunying Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Lirong Teng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China.
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China.
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100010, China
- National Clinical Research Center for Obstetrics and Gynecologic Diseases, Beijing, 100010, China
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Aalipour S, Salmanian B, Fox KA, Clark SL, Shamshirsaz AA, Asl NM, Castro EC, Erfani H, Spinoza J, Nassr A, Belfort MA, Shamshirsaz AA. Placenta Accreta Spectrum: Correlation between FIGO Clinical Classification and Histopathologic Findings. Am J Perinatol 2023; 40:149-154. [PMID: 33934319 DOI: 10.1055/s-0041-1728834] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. STUDY DESIGN We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. RESULTS Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications. CONCLUSION The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. KEY POINTS · PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..
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Affiliation(s)
- Soroush Aalipour
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Steven Leigh Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nazlisadat Meshinchi Asl
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Eumenia C Castro
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jimmy Spinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Yin Y, Qu L, Jin B, Yang Z, Xia J, Sun L, Zhou X. Spiral Suture of the Lower Uterine Segment with Temporary Aortic Balloon Occlusion in Morbidly Adherent Placenta Previa Cases. Int J Womens Health 2022; 14:1161-1171. [PMID: 36046176 PMCID: PMC9422986 DOI: 10.2147/ijwh.s367654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to investigate the combined effect of spiral suture of the lower uterine segment with intraoperative aortic balloon occlusion in morbidly adherent placenta previa cases. Patient and Methods This retrospective, single-center study involved patients from 2017 to 2020. The study considered 68 cases of morbidly adherent placenta previa cases from medical records retrospectively with age ranging from 23 to 42 years. Bilateral uterine artery embolization was performed, to control excessive bleeding. Perioperative blood loss, hysterectomy rate, amount of blood transfusion, balloon occlusion time, fetal and maternal radiation dose, and postpartum complications were assessed. Results A total of 68 patients underwent surgery. Hysterectomy was performed in three patients and uterine artery embolization in 21 patients. Of 53 patients who required blood transfusions, the amount of packed red blood cells given was 800 mL and the amount of plasma given was 400 mL. Median abdominal aortic balloon occlusion time was 17 minutes. Fetal and maternal radiation doses were 5 mGy and 12 mGy, respectively. One patient experienced surgery-related complications, a bladder injury. No major catheterization-related and postpartum complications were observed. Conclusion Fertility-sparing surgery for women with morbidly adherent placenta could include abdominal aortic balloon occlusion and spiral suture of lower uterine segment.
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Affiliation(s)
- Yin Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Lin Qu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Bai Jin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Zhengqiang Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Jinguo Xia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Lizhou Sun
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Xin Zhou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
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Abstract
The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.
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Movahedi M, Niakan Z, Shahshahan Z, Hooshmand Meibodi AR, Babak A, Saeidi M. Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2022; 27:63. [PMID: 36353346 PMCID: PMC9639719 DOI: 10.4103/jrms.jrms_763_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Placenta adherent abnormality (PAA) is abnormal attachment of the placenta to the myometrium. This abnormal placenta binding has severe clinical consequences for the mother and the fetus. We investigated the outcomes of hypogastric arterial ligation (HAL) before hysterectomy compared to hysterectomy alone in pregnant women with PAA. MATERIALS AND METHODS In this randomized controlled clinical trial, 70 patients were randomly allocated to HAL along with hysterectomy and hysterectomy alone groups (35 in each Group). The total amount of intraoperative blood loss, the need for intraoperative blood products transfusion, frequency of deep vein thrombosis, duration of surgery, duration of hospitalization, and visceral trauma were compared between 2 Groups. RESULTS Finally, 64 patients completed the study protocol with mean age of 33.84 ± 4.25 years. The study groups were comparable in terms of basic baseline demographic and clinical characteristics. Visceral trauma was less frequently occurred in HAL group compared to hysterectomy alone (0% vs. 15.6%; P = 0.02). Intraoperative blood loss (1525 ± 536.41 cc vs. 2075 ± 889.36 cc; P = 0.001) and were significantly lower in HAL group compared to hysterectomy alone. Duration of operation (179.06 ± 36.28 vs. 197.66 ± 39.47; P = 0.05) and hospitalization (4.97 ± 2.20 vs. 6.10 ± 2.39; P = 0.03) also were significantly lower in HAL group. CONCLUSION Our findings suggest that prophylactic HAL has a protective effect on the reduction of blood loss and less visceral trauma in pregnant women with PAA.
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Affiliation(s)
- Minoo Movahedi
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Niakan
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Shahshahan
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Anahita Babak
- Department of Community and Family Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmoud Saeidi
- Department of Surgery, School of Medicine Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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Pain F, Dohan A, Grange G, Marcellin L, Uzan‐Augui J, Goffinet F, Soyer P, Tsatsaris V. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand 2022; 101:1135-1145. [PMID: 35822244 PMCID: PMC9812204 DOI: 10.1111/aogs.14420] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/05/2022] [Accepted: 06/18/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The objective of this study was to assess the performance of ultrasound and magnetic resonance imaging (MRI) features in helping to classify the type of placenta accreta spectrum (PAS; accreta/increta vs percreta), alone or combined in a predictive score. MATERIAL AND METHODS We conducted a retrospective study in 82 pregnant women with PAS who underwent ultrasound and MRI examination of the pelvis before delivery (from an initial cohort of 185 women with PAS). We estimated the sensitivity, specificity and accuracy of MRI and ultrasound in the diagnosis of the type of PAS. We analyzed cesarean and imaging features using univariable logistic regression analysis. We constructed a nomogram to predict the risk of placenta percreta and validated it with bootstrap resampling, then used receiver operating characteristic curves to assess the performance of the model in distinguishing between placenta percreta and placenta accreta/increta. RESULTS Among the 82 patients, 29 (35%) had placenta accreta/increta and 53 (65%) had placenta percreta. The best features to discriminate between placenta accreta/increta and placenta percreta with ultrasound were increased vascularization at the uterine serosa-bladder wall interface (odds ratio [OR] 7.93; 95% confidence interval [CI] 2.78-24.99; p < 0.01) and the number of lacunae without a hyperechogenic halo (OR 1.36; 95% CI 1.14-1.67; p = 0.012). Concerning MRI markers, heterogeneous placenta (OR 12.89; 95% CI 3.05-89.16; p = 0.002), dark intraplacental bands (OR 12.89; 95% CI 3.05-89.16; p = 0.002) and bladder wall interruption (OR 15.89; 95% CI 4.78-73.33; p < 0.001) had a higher OR in discriminating placenta accreta/increta from placenta percreta. The nomogram yielded areas under the curve of 0.841 (95% CI 0.754-0.927) and 0.856 (95% CI 0.767-0.945), after bootstrap resampling, for the accurate prediction of placenta percreta. CONCLUSIONS The nomogram we developed to predict the risk of placenta percreta among patients with PAS had good discriminative capabilities. This performance and its impact on maternal morbidity should be confirmed by future prospective studies.
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Affiliation(s)
- Flore‐Anne Pain
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Anthony Dohan
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Gilles Grange
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Louis Marcellin
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | | | - François Goffinet
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | - Philippe Soyer
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Vassilis Tsatsaris
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
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Vestal NL, Sangara RN, Mandelbaum RS, Matsuzaki S, McCarthy LE, Matsushima K, Yoshihara K, Klar M, Lee RH, Ouzounian JG, Matsuo K. Racial and ethnic disparity in characteristics and outcomes of women with placenta accreta spectrum: a comparative study. Reprod Sci 2022; 29:1988-2000. [PMID: 34716538 DOI: 10.1007/s43032-021-00781-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/19/2021] [Indexed: 02/05/2023]
Abstract
Placenta accreta spectrum (PAS) refers to the spectrum of diagnoses involving abnormally and morbidly adherent trophoblastic tissue to the gravid uterus. These disorders are associated with significant maternal morbidity and mortality. While race/ethnicity is known to impact pregnancy outcomes, racial disparities have not been previously examined in women with PAS. The objective of current study was to compare patient characteristics and perioperative outcomes of women with PAS who underwent cesarean delivery across race/ethnicity. This is a comparative study that retrospectively queried the National Inpatient Sample, a hospital-based inpatient database in the USA. The study cohort was women diagnosed with PAS who underwent cesarean delivery from 10/2015 to 12/2018. The exposure group was race/ethnicity. Main outcomes were (i) patient/pregnancy characteristics and (ii) surgical morbidity for cesarean delivery, assessed in multivariable analysis. A total of 10,535 women comprised the study cohort (White n = 5,230 [49.6%], Black n = 2,045 [19.4%], Hispanic n = 2,540 [24.1%], and Asian n = 720 [6.8%]). Patient demographics, pregnancy characteristics, and hospital factors for the non-White groups significantly differed compared to the White group. Older age, obesity, diabetes, placenta previa, percreta, non-elective surgery, lower median household income, and Medicaid particularly represented the non-White groups. When perioperative outcomes were compared, non-White women were more likely to have any measured complications, hemorrhage/transfusion, and shock/coagulopathy compared to White women. Various sensitivity analyses redemonstrated the main cohort results. In conclusion, this study suggests that there were significant disparities in patient characteristics and outcomes of women with PAS across race/ethnicity.
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Affiliation(s)
- Nicole L Vestal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Lauren E McCarthy
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Richard H Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA.
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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Munoz JL, Pfeiffer AF, Ramsey PS. Correlation of clinical outcomes with the application of the 2020 consensus panel on histological classification for Placenta Accreta Spectrum (PAS). J Matern Fetal Neonatal Med 2022; 35:10044-10048. [PMID: 35703727 DOI: 10.1080/14767058.2022.2086797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Placenta Accreta Spectrum (PAS) is a range of disorders characterized by placenta adherence to uterine myometrium. The pathologic nomenclature of PAS has varied. In 2020, a consensus panel proposed a system which would parallel the antenatal grading. Our goal was to assess if greater PAS associated morbidity correlated with increasing histopathological grades in this novel system for confirmed cases of PAS. METHODS A retrospective cohort analysis was performed of 125 singleton, non-anomalous pregnancies complicated by PAS at the University of Texas Health San Antonio Placenta Accreta program from 2005 to 2020. PAS cases confirmed after cesarean hysterectomy were classified by the new system and outcomes were analyzed including Kaplan-Meier analysis of gestational age at delivery by new pathology categorization. RESULTS Antepartum admission, length of stay and episodes of vaginal bleeding correlated with increasing grades of PAS. In addition, increased PAS grades were associated with deliveries at earlier gestational age and surgical outcomes including operative time, blood loss, ICU admission and post-operative length of stay. CONCLUSIONS The grading system proposed by the 2020 consensus panel correlates with antepartum, intra-operative and postoperative outcomes in cases of PAS cesarean hysterectomy and should be implemented for uniformity of reporting.
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Affiliation(s)
- Jessian L Munoz
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, Texas
| | - Alixandria F Pfeiffer
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, Texas
| | - Patrick S Ramsey
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, Texas
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Sentilhes L, Seco A, Azria E, Beucher G, Bonnet MP, Branger B, Carbillon L, Chiesa C, Crenn-Hebert C, Dreyfus M, Dupont C, Fresson J, Huissoud C, Langer B, Morel O, Patrier S, Perrotin F, Raynal P, Rozenberg P, Rudigoz RC, Vendittelli F, Winer N, Deneux-Tharaux C, Kayem G. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. Am J Obstet Gynecol 2022; 226:839.e1-839.e24. [PMID: 34914894 DOI: 10.1016/j.ajog.2021.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/24/2021] [Accepted: 12/09/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. OBJECTIVE This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). STUDY DESIGN From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. RESULTS Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. CONCLUSION Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.
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Affiliation(s)
- Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| | - Aurélien Seco
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France; Clinical Research Unit of Paris Descartes Necker Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Elie Azria
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France; Maternité Notre-Dame de Bon Secours, Groupe Hospitalier Paris Saint-Joseph, Paris University, Paris, France
| | - Gaël Beucher
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - Marie-Pierre Bonnet
- Department of Anesthesia and Critical Care, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Bernard Branger
- "Sécurité Naissance-Naître Ensemble" Perinatal Network of the Pays de la Loire, Pays de la Loire, France
| | - Lionel Carbillon
- "Naître dans l'Est Francilien" Perinatal Network, Sorbonne Paris North University, Villetaneuse, France
| | - Coralie Chiesa
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France
| | - Catherine Crenn-Hebert
- Department of Obstetrics and Gynecology, Louis-Mourier University Hospital, Assistance Publique-Hôpitaux de Paris, Colombes, France; "Hauts de Seine" (PERINAT92) Perinatal Network, Issy-les-Moulineaux, Paris, France
| | - Michel Dreyfus
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - Corinne Dupont
- Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France; "Aurore" Perinatal Network, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Jeanne Fresson
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France; Department of Medical Information, Nancy University Hospital, Nancy, France
| | - Cyril Huissoud
- Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France; Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Bruno Langer
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - Olivier Morel
- Department of Obstetrics and Gynecology, Nancy University Hospital, Nancy, France
| | - Sophie Patrier
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Tours University Hospital, Tours, France
| | - Pierre Raynal
- Department of Obstetrics and Gynecology, Versailles Hospital, Versailles, France
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy University Hospital, Poissy, France
| | - René-Charles Rudigoz
- Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France; Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Croix-Rousse Hospital, Lyon, France
| | - Francoise Vendittelli
- Auvergne Perinatal Network, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France; Department of Obstetrics and Gynecology, University Hospital of Clermont-Ferrand, Scientific Research National Center, SIGMA Clermont, Institute Pascal, Clermont-Ferrand, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France
| | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France
| | - Gilles Kayem
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, National Institute of Health and Medical Research, National Institute of Agronomic Research, Centre for Epidemiology and Statistics Sorbonne Paris Cité, Paris University, Paris, France; Department of Obstetrics and Gynecology, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Risk of Subsequent Hysterectomy after Expectant Management in the Treatment of Placenta Accreta Spectrum Disorders. Medicina (B Aires) 2022; 58:medicina58050678. [PMID: 35630092 PMCID: PMC9144771 DOI: 10.3390/medicina58050678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/17/2022] Open
Abstract
Management strategies for pregnancies with abnormal adherence/invasion of the placenta (placenta accreta spectrum, PAS) vary between centers. Expectant management (EM), defined as leaving the placenta in situ after the delivery of the baby, until its complete decomposition and elimination, has become a potential option for PAS disorders in selected cases, in which the risk of Caesarean hysterectomy is very high. However, expectant management has its own risks and complications. The aim of this study was to describe the rates of subsequent hysterectomy (HT) in patients that underwent EM for the treatment of PAS disorders. We reviewed the literature on the subject and found 12 studies reporting cases of HT after initial intended EM. The studies included 1918 pregnant women diagnosed with PAS, of whom 518 (27.1%) underwent EM. Out of these, 121 (33.2%) required subsequent HT in the 12 months following delivery. The rates of HT after initial EM were very different between the studies, ranging from 0 to 85.7%, reflecting the different characteristics of the patients and different institutional management protocols. Prospective multicenter studies, in which the inclusion criteria and management strategies would be uniform, are needed to better understand the role EM might play in the treatment of PAS disorders.
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Overton E, Booker WA, Mourad M, Moroz L, Nhan Chang CL, Breslin N, Syeda S, Laifer-Narin S, Cimic A, Chung DE, Weiner DM, Smiley R, Sheikh M, Mobley DG, Wright JD, Gockley A, Melamed A, St Clair C, Hou J, D'Alton M, Khoury Collado F. Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum. Am J Obstet Gynecol MFM 2022; 4:100657. [PMID: 35597402 DOI: 10.1016/j.ajogmf.2022.100657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado).
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Leslie Moroz
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Chia-Ling Nhan Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Noelle Breslin
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sbaa Syeda
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sherelle Laifer-Narin
- Department of Diagnostic Radiology, Columbia University, New York, NY (Dr Laifer-Narin)
| | - Adela Cimic
- Department of Anatomic Pathology, Columbia University, New York, NY (Dr Cimic)
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - David M Weiner
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - Richard Smiley
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - Maria Sheikh
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - David G Mobley
- Division of Interventional Radiology, Columbia University, New York, NY (Dr Mobley)
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Allison Gockley
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Caryn St Clair
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - June Hou
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Fady Khoury Collado
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
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Salmanian B, Shainker SA, Hecht JL, Modest AM, Castro EC, Seaman RD, Meshinchiasl N, Hessami K, Brown A, Tounsi S, Shamshirsaz AA, Fox KA, Clark SL, Belfort MA, Shamshirsaz AA. The Society for Pediatric Pathology Task Force grading system for placenta accreta spectrum and its correlation with clinical outcomes. Am J Obstet Gynecol 2022; 226:720.e1-720.e6. [PMID: 35139335 DOI: 10.1016/j.ajog.2022.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease. OBJECTIVE In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system. STUDY DESIGN The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed. RESULTS A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (β=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072). CONCLUSION The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.
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Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Scott A Shainker
- Departments of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Anna M Modest
- Departments of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eumenia C Castro
- Department of Pathology, Baylor College of Medicine, Houston, TX
| | - Rachel D Seaman
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | | | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Alec Brown
- Departments of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah Tounsi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
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Guan X, Huang X, Ye M, Huang G, Xiao X, Chen J. Treatment of Placenta Increta With High-Intensity Focused Ultrasound Ablation and Leaving the Placenta in situ: A Multicenter Comparative Study. Front Med (Lausanne) 2022; 9:871528. [PMID: 35463039 PMCID: PMC9021530 DOI: 10.3389/fmed.2022.871528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To explore the feasibility of simple high-intensity focused ultrasound (HIFU) ablation for placenta increta. Methods Ninety-five patients after a vaginal delivery were enrolled in this retrospective cohort study, 53 patients were treated with simple HIFU ablation, and 42 patients were treated with HIFU followed by uterine curettage. Results All 95 patients were successfully treated with a single-session HIFU procedure, and in the control group, the necrotic placental tissue was removed with curettage. Vaginal hemorrhage did not occur in either group. The duration of bloody lochia was 25.9 ± 8.6 days in the sHIFU group and 24.2 ± 8.8 days in the control group (P > 0.05). The median serum human chorionic gonadotropin (HCG) level was 3,222 mIU/mL and 2,838 mIU/mL in the sHIFU and control groups, respectively, which decreased and returned to normal within 30 days, and the differences were not significantly on comparing the blood HCG level in the two groups at 7, 15, and 30 days after HIFU (all P > 0.05). Decreased menstrual volume occurred in 85.71% of patients in the control group, which was higher than that in the sHIFU group (23.08%) (χ2 = 6.839, P < 0.001). During 2–8 years of follow-up, six pregnancies occurred in the sHIFU group without any recurrence of placenta increta, three pregnancies occurred in the control group, and one patient developed a repeat placenta increta. Conclusion Simple HIFU treatment is safe and effective for postpartum placenta increta and leaving the placenta in situ. It is a promising option for patients who wish to preserve their fertility and conceive.
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Affiliation(s)
- Xiaoping Guan
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Department of Gynecology, Neijiang First People's Hospital, Neijiang, China
| | - Xiaoqin Huang
- Department of Gynecology, Neijiang First People's Hospital, Neijiang, China
| | - Min Ye
- Department of Gynecology, Neijiang First People's Hospital, Neijiang, China
| | - Guohua Huang
- Department of Gynecology, Suining Central Hospital, Suining, China
| | - Xiao Xiao
- Department of Gynecology, Chongqing Haifu Hospital, Chongqing, China
| | - Jinyun Chen
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Department of Gynecology, Chongqing Haifu Hospital, Chongqing, China
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An P, Zhang J, Yang F, Wang Z, Hu Y, Li X. USMRI Features and Clinical Data-Based Model for Predicting the Degree of Placenta Accreta Spectrum Disorders and Developing Prediction Models. Int J Clin Pract 2022; 2022:9527412. [PMID: 35685563 PMCID: PMC9159129 DOI: 10.1155/2022/9527412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 11/18/2022] Open
Abstract
AIM This study aimed to investigate the ability of ultrasound/magnetic resonance imaging (MRI) signature and clinical data-based model for preoperatively predicting the degree of placenta accreta spectrum disorders and develop combined prediction models. METHODS The clinicopathological characteristics, prenatal ultrasound images, and MRI features of 132 pregnant women with placenta accreta spectrum disorders at Xiangyang No. 1 People's Hospital were retrospectively reviewed from January 2016 to December 2020. In the training set of 99 patients, the ultrasound/MRI features model, clinical characteristics model, and combined model were developed by multivariate logistic regression analysis to predict the degree of placenta accreta spectrum disorders. The prediction performance of different models was compared using the Delong test. The developed models were validated by assessing their prediction performance in a test set of 33 patients. RESULTS The multivariate logistic regression analysis identified history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder to construct a combined model for predicting the degree of placenta accreta spectrum disorders (area under the curve (AUC) = 0.931; 95% confidence interval (CI): 0.882-0.980). The AUC of the clinical characteristics model and ultrasound/MRI features model was 0.858 (95% CI 0.794-0.921) and 0.709 (95% CI 0.624-0.798), respectively. The AUC of the combined model was significantly higher than that of the ultrasound/MRI features model (P < 0.001) or clinical characteristics model (P < 0.0015) in the training set. In the test set, the combined model also showed higher prediction performance. CONCLUSIONS Ultrasound/MRI-based signature is a powerful predictor for the degree of placenta accreta spectrum disorders in an early stage. A combined model (constructed with history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder) can improve the accuracy for predicting the degree of placenta accreta spectrum disorders in an early stage.
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Affiliation(s)
- Peng An
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, The First Clinical Medical College, 155 Hanzhong Road, Nanjing 210029, Jiangsu Province, China
| | - Junyan Zhang
- Department of Pharmacy and Laboratory, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Feng Yang
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Zhongqiu Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, The First Clinical Medical College, 155 Hanzhong Road, Nanjing 210029, Jiangsu Province, China
| | - Yan Hu
- Department of Pharmacy and Laboratory, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Xiumei Li
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
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Guo Z, Han X, Zheng W, Yang H, Ma J. Placenta Accreta Spectrum Among Multiple Gestation: A Retrospective Analysis Based on a Chinese Population. Front Endocrinol (Lausanne) 2022; 13:862785. [PMID: 35663330 PMCID: PMC9158523 DOI: 10.3389/fendo.2022.862785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It remained controversial whether women with multiple gestation are at higher risk of placenta accreta spectrum (PAS) disorders and large-scale studies are needed. This study aimed to assess whether PAS incidence is higher among women with multiple gestation than among singleton, as well as to compare the characteristics and outcomes of PAS in multiple and singleton gestation. METHODS Women who underwent cesarean section with live births at Peking University First Hospital from January 2015 to December 2020 were included. Demographic and clinical information was collected through chart review. Logistic regression models were used to analyze the associations between multiple gestation and PAS. The clinical characteristics and perioperative outcomes of PAS in multiple and singleton gestation were further compared. RESULTS Among the 14583 women included, 2.4% (352/14583) were diagnosed with PAS. PAS was slightly more prevalent among multiple gestations than among singletons (2.5% vs 2.4%, P=0.857). After adjusting for known risk factors and pregnancy complications, multiple gestation was associated with a higher risk of PAS (aOR=1.63, 95% CI 1.01-2.62). Among PAS patients, women who had multiple births had a significantly lower rate of previous cesarean deliveries (27.6% vs. 56.3%, P=0.003), placenta previa (17.2% vs. 56.3%, P<0.001) and invasive PAS (24.1% vs. 53.9, P=0.002) than singletons. There were no significant differences in perioperative outcomes between these two groups. CONCLUSION Multiple gestation could be independently associated with an elevated risk of PAS. The clinical characteristics of PAS in the multiple and singleton gestation groups differed significantly in cesarean delivery history and placenta previa. The results of this study may inform guidelines on the screening, early detection and timely intervention of PAS patients among women with multiple births.
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Affiliation(s)
- Zhirong Guo
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Xueyan Han
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
- *Correspondence: Huixia Yang, ; Jingmei Ma,
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
- *Correspondence: Huixia Yang, ; Jingmei Ma,
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Alhousseini A, Romero R, Benshalom-Tirosh N, Gudicha D, Pacora P, Tirosh D, Kabiri D, Yeo L, Thachil J, Hsu CD, Hassan SS, Erez O. Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion. J Matern Fetal Neonatal Med 2022; 35:242-257. [PMID: 31931643 PMCID: PMC9019739 DOI: 10.1080/14767058.2020.1716330] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy. OBJECTIVES (1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score. STUDY DESIGN This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion. RESULTS (1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion. CONCLUSION We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.
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Affiliation(s)
- Ali Alhousseini
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA,Detroit Medical Center, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Miami International University, Miami, Florida, USA
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dereje Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dan Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Maternity Department “D,” Division of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Munoz JL, Hernandez B, Ireland KE, Ramsey PS. Short interval pregnancy is associated with pathology severity in placenta accreta spectrum (PAS). J Matern Fetal Neonatal Med 2021; 35:8863-8868. [PMID: 34818975 DOI: 10.1080/14767058.2021.2005571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a continuum of invasive pathologies associated with significant maternal morbidity and mortality. Pregnancies with short intervals present additional complications which may result from suboptimal wound healing. The impact of short interval pregnancy on placental invasion is unknown our primary objective was to characterize the impact of short interval pregnancy in the subsequent invasive degree of PAS. METHODS Here we present a retrospective case-control analysis of 133 patients with pathology-confirmed PAS who presented to our Placenta Accreta program and assessed for the impact of short interval pregnancy (<18 months) as an independent risk factor for the development of advanced pathology. RESULTS 33.8% (45/133) of patients with PAS had pregnancies complicated by short intervals between gestations. Short interval pregnancies were significantly associated with placenta percreta/increta pathology (p = .006). Ordinal logistic regression showed an inversely proportional relationship between short-interval pregnancy and the degree of placental invasion (OR 2.91 [95% CI 1.02, 4.05]). CONCLUSION Short interval pregnancies are at increased risk for greater degrees of placenta invasion seen in placenta increta and percreta when compared to interpregnancy interval >18 months. This relationship is inversely proportional and consistent at shorter intervals. Thus, when counseling patients on their overall risk of placental invasive pathology, short interval pregnancy may be considered a significant risk factor.
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Brian Hernandez
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Kayla E Ireland
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Patrick S Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
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Huang J, Zhang X, Liu L, Duan S, Pei C, Zhao Y, Liu R, Wang W, Jian Y, Liu Y, Liu H, Wu X, Zhang W. Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control. Front Med (Lausanne) 2021; 8:557678. [PMID: 34733857 PMCID: PMC8558214 DOI: 10.3389/fmed.2021.557678] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the use of tourniquet and forceps to reduce bleeding during surgical treatment of severe placenta accreta spectrum (placenta increta and placenta percreta). Methods: A tourniquet was used in the lower part of the uterus during surgical treatment of severe placenta accreta spectrum. Severe placenta accreta spectrum was classified into two types according to the relative position of the placenta and tourniquet during surgery: upper-tourniquet type, in which the entire placenta was above the tourniquet, and lower-tourniquet type, in which part or all of the placenta was below the tourniquet. The surgical effects of the two types were retrospectively compared. We then added forceps to the lower-tourniquet group to achieve further bleeding reduction. Finally, the surgical effects of the two types were prospectively compared. Results: During the retrospective phase, patients in the lower-tourniquet group experienced more severe symptoms than did patients in the upper-tourniquet group, based on mean intraoperative blood loss (upper-tourniquet group 787.5 ml, lower-tourniquet group 1434.4 ml) intensive care unit admission rate (upper-tourniquet group 1.0%, lower-tourniquet group 33.3%), and length of hospital stay (upper-tourniquet group 10.2d, lower-tourniquet group 12.1d). During the prospective phase, after introduction of the revised surgical method involving forceps (in the lower-tourniquet group), the lower-tourniquet group exhibited improvements in the above indicators (intraoperative average blood loss 722.9 ml, intensive care unit admission rate 4.3%, hospital stays 9.0d). No increase in the rate of complications was observed. Conclusion: The relative positions of the placenta and tourniquet may influence the perioperative risk of severe placenta accreta spectrum. The method using a tourniquet (and forceps if necessary) can improve the surgical effect in cases of severe placenta accreta spectrum.
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Affiliation(s)
- Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Xiaowen Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Lijuan Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Si Duan
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Chenlin Pei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yanhua Zhao
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Rong Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Weinan Wang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yu Jian
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yuelan Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Hui Liu
- Department of Radiology, Xiangya Hospital Central South University, Changsha, China
| | - Xinhua Wu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China.,Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
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Matsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, Matsushima K, Amaya R, Ouzounian JG, Matsuo K. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021; 225:534.e1-534.e38. [PMID: 33894149 DOI: 10.1016/j.ajog.2021.04.233] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
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Affiliation(s)
- Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Lauren E McCarthy
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Nicole L Vestal
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Shazly SA, Anan MA, Makukhina TB, Melekoglu R, Ahmed FUA, Pinto PV, Takahashi H, Ahmed NB, Sayed EG, Elassall GM, Said AE, Fahmy MS, Dawyee DM, Penzhoyan GA, Amirkhanyan AM, Yılmaz E, Celik NZ, Aziz H, Akhter T, Ambreen A, Abdelbadie AS. Placenta accreta risk-antepartum score in predicting clinical outcomes of placenta accreta spectrum: A multicenter validation study. Int J Gynaecol Obstet 2021; 158:424-431. [PMID: 34674270 DOI: 10.1002/ijgo.13993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To validate the use of placenta accreta risk-antepartum (PAR-A) score as a predictive tool of clinical outcomes of placenta accreta spectrum (PAS). METHODS This is a prospective study, conducted in six PAS specialized centers in six different countries. The study was conducted between October 1, 2020 and March 31, 2021. Women who were provisionally diagnosed with PAS during pregnancy were considered eligible. A machine-learning-based PAR-A score was calculated. Diagnostic performance of the PAR-A score was evaluated using a receiver operating characteristic curve, for perioperative massive blood loss and admission to intensive care unit (ClinicalTrials.gov identifier NCT04525001). RESULTS Of 97 eligible women, 86 were included. PAS-associated massive blood loss occurred in 10 patients (11.63%). Median PAR-A scores of massive blood loss in the current cohort were 8.9 (interquartile range 6.9-14.1). In predicting massive blood loss, the area under the curve of PAR-A scores was 0.85 (95% confidence interval [CI] 0.74-0.95), which was not significantly different from the original cohort (P = 0.2). PAR-A score prediction of intensive care unit admission was slightly higher compared with the original cohort (0.88, 95% CI 0.81-0.95; P = 0.06). CONCLUSION PAR-A score is a novel scoring system of PAS outcomes, which showed external validity based on current data.
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Affiliation(s)
- Sherif A Shazly
- Women's services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mohamed A Anan
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
| | - Tatiana B Makukhina
- Obstetrics, Gynecology, and Perinatology Department of the Faculty of Postgraduate Education, Kuban State Medical University, Krasnodar, Russia.,State Budgetary Healthcare Institution "Regional Clinical Hospital No. 2" of the Ministry of Health of the Krasnodar Territory, Perinatal Center, Krasnodar, Russia
| | - Rauf Melekoglu
- Department of Obstetrics and Gynecology, School of Medicine, Inonu University, Malatya, Turkey
| | - Farhat Ul A Ahmed
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Lahore, Pakistan
| | - Pedro V Pinto
- Serviço de Ginecologia e Obstetrícia, Centro Hospitalar São João, Porto, Portugal
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
| | | | - Esraa G Sayed
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Aliaa E Said
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed S Fahmy
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
| | - Diaa M Dawyee
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
| | - Gregory A Penzhoyan
- Obstetrics, Gynecology, and Perinatology Department of the Faculty of Postgraduate Education, Kuban State Medical University, Krasnodar, Russia
| | - Arpine M Amirkhanyan
- Obstetrics, Gynecology, and Perinatology Department of the Faculty of Postgraduate Education, Kuban State Medical University, Krasnodar, Russia.,State Budgetary Healthcare Institution "Regional Clinical Hospital No. 2" of the Ministry of Health of the Krasnodar Territory, Perinatal Center, Krasnodar, Russia
| | - Ercan Yılmaz
- Department of Obstetrics and Gynecology, School of Medicine, Inonu University, Malatya, Turkey
| | - Nesibe Z Celik
- Department of Obstetrics and Gynecology, School of Medicine, Inonu University, Malatya, Turkey
| | - Hijab Aziz
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Lahore, Pakistan
| | - Tayyaba Akhter
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Lahore, Pakistan
| | - Afshan Ambreen
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Lahore, Pakistan
| | - Amr S Abdelbadie
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
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